PFFs are an increasing burden presenting to the acute trauma services. The purpose of this study is to show that cemented revision for Vancouver B2/B3 PFFs is a safe option in the geriatric population, allows early pain-free weight bearing and comparable to a control-group of uncemented stems with regard to return to theatre and revision surgery. A retrospective review was conducted of all PFFs treated in a Level 1 trauma centre from 2015-2020. Follow up x-rays and clinical course through electronic chart was reviewed for 78 cemented revisions and 49 uncemented revisions for PFF. Primary endpoints were all cause revision and return to theatre for any reason. Secondary endpoints recorded mobility status and all-cause mortality. In the cemented group there were 73 Vancouver B2, 5 Vancouver B3 PFF; the mean age was 79.7 years and mean radiological follow-up of 11.9 months. In the cementless group there were 32 Vancouver B2 and 17 Vancouver B3 PFFs; with all 49 patients undergoing distally bearing uncemented revision, the mean age was 72.7 years and mean radiological follow-up of 21.3 months. Patients treated with a cemented prosthesis had significantly higher ASA score (2.94 -v- 2.43, p<0.001). The primary endpoints showed that there was no significant difference in all cause revision 3/78 and 5/49 p=0.077, or return to theatre 13/78 -v- 12/49 p=0.142. Secondary endpoints revealed no significant difference in in-hospital mortality. The cementless group were more likely to be mobilising without any aid at latest follow-up 35/49 -v- 24/78 p<0.001. The use of cemented revision femoral component in the setting of PFFs is one option in the algorithm for management of unstable PFFs according to the Vancouver classification. Evidence from this case-control study, shows that the all-cause revision and return to theatre for any cause was comparable in both groups

Introduction. Hydroxyapatite (HA) coated femoral stems require a press fit for initial stability prior to osteointegration occurring. However this technique can lead to perioperative femoral fracture. Materials and Methods. 506 consecutive patients under 72 years who underwent primary total hip replacements (THR) under 72 years were investigated for perioperative femoral fractures. All patients were independently assessed pre- and post-operatively in a research clinic. Assessment was made by Merle d'Aubigné and Postel (MDP) hip scores and radiographs. Between 1995 and 2001 patients were randomised to a partially HA coated, Osteonics Omnifit or fully HA coated Joint Replacement Instrumentation Furlong stem. Between 2001 and 2004 all patients received an Anatomique Benoist Girard (ABG II) stem partially coated. Fractures were identified from check radiographs and operative notes. The type of fracture was classified according to the modified Vancouver classification. The incidence of revision was also recorded. Results. There were 38 fractures (7.5%) overall. The Omnifit group had 9 fractures (7.4%) the Furlong 11 (8.9%) and the ABG II 18 (6.7%). Twenty-four cases were treated by internal fixation at the time of primary surgery. Four cases had an unsatisfactory result and two were revised. Fourteen had conservative treatment. Seven of these had an unsatisfactory result and four required early revision. The difference between the operated and conservative treatment groups was significant (P<0.01). There was a correlation between Vancouver classification and outcome. Conclusion. Perioperative fracture is relatively common. The type of fracture has an influence on the outcome. Unstable fracture patterns require internal fixation at the time of initial surgery

The most common classification of periprosthetic femoral fractures is the Vancouver classification. The classification has been validated by multiple centers. Fractures are distinguished by location, stability of the femoral component, and bone quality. Although postoperative and intraoperative fractures are classified using the same three regions, the treatment algorithm is slightly different. Type A fractures involve the greater and lesser trochanter. Fractures around the stem or just distal to the stem are Type B and subcategorised depending on stem stability and bone quality. Type C fractures are well distal to the stem and are treated independent of the stem with standard fixation techniques. The majority of fractures are either B1 (stable stem) or B2 (unstable stem). The stem is retained and ORIF of the fracture performed for B1 fractures. B2 and B3 fractures require stem revision with primary stem fixation distal to the fracture. Intraoperative fractures use the same A, B, C regions but are subtyped 1–3 as cortical perforations, nondisplaced, and displaced unstable fractures, respectively. With the exception of A1 intraoperative fractures all other intraoperative fractures require surgical treatment. A recent publication utilizing a New York state registry highlighted the patient risk of mortality associated with periprosthetic hip fractures. One month, 6 month and 1 year mortality was 3.2%, 3.8% and 9.7%, respectively. The mortality risk was lower for periprosthetic fractures treated with ORIF at 1 and 6 months compared to fractures requiring revision total hip

Introduction. In recent years, there has been an increase in hip joint replacement surgery using short bone-preserving femoral stem. However, there are very limited data on postoperative periprosthetic fractures after cementless fixation of these stem although the periprosthetic fracture is becoming a major concern following hip replacement surgery. The purpose of this study is to determine incidence of postoperative periprosthetic femoral fractures following hip arthroplasty using bone preserving short stem in a large multi-center series. Materials & Methods. We retrospectively reviewed 897 patients (1089 hips) who underwent primary total hip arthroplasty (THA) or bipolar hemiarthroplasty (BHA) during the same interval (2011–2016) in which any other cementless, short bone-preserving femoral stem was used at 7 institutions. During the study, 1008 THAs were performed and 81 BHAs were performed using 4 different short femoral prostheses. Average age was 57.4 years (range, 18 – 97 years) with male ratio of 49.7% (541/1089). Postoperative mean follow-up period was 1.9 years (range, 0.2 – 7.9 years). Results. Overall incidence of postoperative periprosthetic femoral fractures was 1.1% (12/1089). The mean age of these 12 patients were 71.2 year (range, 43 – 86 years). Seven patients were female and other 5 were male. Time interval between primary arthroplasty and fracture were mean 1.1 years (range, 0.1 – 4.8 years). Injury mechanism is a slip in 10 fractures and fall from 1m or less in 2. Three fractures occurred after BHA while 9 occurred after THA. Four fractures were in type AG and other 8 were in type B1 according to Vancouver classification. Of the 4 with AG type, 2 underwent open reduction and internal fixation and 2 took conservative management. Of the 8 with B1 type, 6 underwent open reduction and internal fixation and 2 took conservative management. Conclusion. The prevalence of postoperative periprosthetic femoral fractures was 1.1% in a multicenter retrospective analysis of 1089 hips. Our findings suggest that postoperative periprosthetic fracture can occur after hip replacement surgery using short bone-preserving stem although the incidence is relatively low

The Vancouver classification separates periprosthetic femur fractures after THA into three regions (A - trochanteric, B - around or just below the stem, and C - well below the stem), with fractures around or just below the stem further separated into those with a well-fixed (B1) or loose stem and good (B2) or poor (B3) bone stock. Trochanteric fractures may be associated with osteolysis and require treatment that addresses osteolysis as well as ORIF of displaced fractures. Fractures around a well-fixed stem can be treated with ORIF using cerclage or cable plating, while those around a loose stem require implant revision usually to a longer cementless tapered or distally porous coated cementless stem. Fractures around a loose stem with poor bone stock in which salvage of the proximal femur is not possible require replacement of the proximal femur with an allograft prosthetic composite or proximal femoral replacement. Fractures well below the stem can be treated with conventional plating methods. Periprosthetic acetabular fractures are rare and usually occur in the early post-operative period or late as a result of osteolysis or trauma. These can generally be separated into those with a stable acetabular component which can be treated non-operatively, and those with an unstable component often with discontinuity or posterior column instability which require complex acetabular reconstruction utilizing plating or revision to a cup-cage

Between 2002 and 2009, 15 patients with periprosthetic fractures of the femur and the acetabulum either intraoperative or perioperative fracures were treated. The intraoperative femoral fracture was treated by circulage and longer stems with excellent results, the postoperative femoral fracture was treated by cable plate systems or revision arthroplasty without the use of cortical strut allograft, all the cases are treated according to Vancouver classification. There are tow cases of intraoperative acetabular fractures, the first one was treated by block autograft and cemented cup, the other one treated by multihole cementless cup as internal plating. The postoperative acetabular fractures are spontaneous fractures due to osteolysis and treated by impaction or allograftwith metal support either by rings or meshes

Peri-prosthetic fractures of the femur around a THA remain challenging injuries to treat. The Vancouver Classification helps to guide decision making, and is based on fracture location, implant fixation status, and remaining bone quality. It is critical to determine fixation status of the implant, even if surgical dislocation is necessary. Type A fractures involve the trochanters, and are usually due to osteolysis. Revision of the bearing surface and bone grafting of the lesions can be effective. Type B1 fractures occur around a well fixed stem, typically at the stem tip. Internal fixation with laterally based locked cable plates is effective. Optimising proximal fixation is important, typically with locked screws and cables. Allograft struts are probably unnecessary with modern angle stable plates. Type B2 and B3 fractures are treated with revision, either with a fully coated cylindrical or a modular fluted tapered titanium stem. Distal fixation should be optimised, while preserving vascularity to proximal bony fragments. The « internal scaffold » technique has been described with excellent results. Rarely, a proximal femoral replacement is necessary. Careful attention to detail and clear knowledge of stem fixation status is necessary for a good outcome

Prevention: Many periprosthetic femur fractures may be prevented by: good patient follow-up; timely reoperation of lytic lesions if radiographs suggest fracture risk; prophylactic use of longer stemmed implants or strut grafts to bypass cortical defects at revision surgery. Treatment: Periprosthetic fractures can be treated using an algorithmic approach based on the Vancouver classification system. Fractures of greater or lesser trochanter (Type A): nonoperative treatment if displacement acceptable and if not associated with lysis; operative treatment if displacement unacceptable or associated with progressive lysis. Fractures of distal femur well distal to implant (Type C): treat as any other femur fracture, usually operatively; fixation options: plate/retrograde nails. Fractures around the implant or at its tip (Type B): these fractures almost always require surgery. Nonoperative treatment is associated with high rate of malunion, nonunion, poor results. Treatment is according to fixation status of implant and bone quality. Well-fixed stem (Type B1): ORIF with cable plate and/or strut grafts; or with locking plate and minimally invasive biologic technique. Loose stem (Type B2 and Type B3): revise implant to long stem; usually use uncemented distally-fixed implant; occasionally long cemented stem (avoid cement extrusion). In most cases we favor use of a modular fluted tapered stem which provides axial and rotational stability by fixation distal to the fracture. Principles: obtain fracture stability, implant stability, and optimise conditions for bone healing (use bone grafts, don't strip periosteum)

A large number of classification systems exist to assist in the evaluation and treatment of periprosthetic fractures following joint replacement. They vary in the language or categorisation they employ, the joints to which they are differently applied, the factors they assess, and the hierarchy or importance assigned to those factors. Not all incorporate the three most important variables which should govern treatment (fracture location, implant fixation, bone quality), nor the factors which have been demonstrated to most prominently influence outcomes. To a greater or lesser extent they attempt to include the principles of the Vancouver Classification System, and yet they differ in ways that lead to awkwardness in their application within the clinical setting. As an example, for fractures of the patella alone, three different systems have been proposed. As the result of an international effort endorsed by the AO/OTA, the Universal Classification System, or UCS, has been developed. It incorporates the most important factors that should influence evaluation, treatment, and outcomes evaluation. It applies the system to the musculoskeletal system as a whole, regardless of the joint involved or the bone that is broken. And it uses a single common language to describe the injury and prescribe the logical principles of treatment. It is hoped the UCS will appeal to our colleagues worldwide and will assist all of us in the care of our patients who suffer a periprosthetic fracture after joint replacement; be that the hip, knee, ankle, shoulder, elbow or wrist. The UCS can be applied with equal ease and merit to all

Periprosthetic fractures present several unique challenges including gaining fixation around implants, poor bone quality and deciding on an appropriate treatment strategy. Early. With the popularity of cementless stems in primary total hip arthroplasty (THA) we have seen a concomitant rise in the prevalence of intra-operative and early post-operative fractures of the femur. While initial press-fit fixation is a requirement for osseointegration to occur, there is a fine balance between optimising initial stability and overloading the strength of the proximal femur. Hence, the risk of intra-operative fractures is intimately related to the design of the femoral component utilized (metaphyseal engaging, wedge shaped designs having the highest risk) and the strength of the bone that it is inserted into (elderly females being at highest risk). These fractures typically are associated with a loose femoral component and require revision to a stem that gains primary fixation distally. We have found a high risk of complications and problems when treating these fractures in the early post-operative period with a high risk of infection, heterotopic ossification and the requirement for subsequent surgery. Late. The Vancouver Classification is based on the location of the fracture, the fixation of the implant and the quality of the surrounding host bone. The most common pitfall in treatment is mistaking a B2 fracture (stem loose) for a B1 (stem stable); treatment of a loose implant with ORIF alone will necessarily fail

With an increasing ageing population and a rise in the number of primary hip arthroplasty, peri-prosthetic fracture (PPF) reconstructive surgery is becoming more commonplace. The Swedish National Hip Registry reported that, in 2002, 5.1% of primary total hip replacements required revision due to PPF. Laboratory studies have indicated that age, bone quality and BMI all contribute to an increased risk of PPF. Osteolysis and aseptic loosening contribute to the formation of loosening zones as described by Gruen, with subsequent increased risk of fracture. The aim of the study was to identify significant risk factors for PPF in patients who have undergone primary total hip replacement (THR). Logbooks of three Consultant hip surgeons were filtered for patients who had THR-PPF fixation subsequent to trauma. Risk factors evaluated included sex, age, bone density (Singhs index), loosening zones, Vancouver classification, prosthesis stem angle relative to the axis of the femur, and length of time from THR to fracture. A control group of uncomplicated primary THR patients was also scrutinised. Forty-six PPF were identified representing 2.59% of THR workload. The male: female ratios in both groups were not significantly different (1:1.27 and 1:1.14 respectively). Average age of PPF was 72.1, which was significantly older than the control group (54.7, p>0.05). The commonest type of PPF was Vancouver type B. Whilst stem position in the AP plane was similar in both groups, in lateral views the PPF stem angle demonstrated significant antero-grade leg position compared to the non-PPF group (p.0.05). The PPF group demonstrated a greater number of loosening zones in pre-fracture radiographs compared to the control group (2.59 and 1.39 respectively, p>0.05). Our workload from PPF reflects that seen in Europe. Age, stem position and the degree of stem loosening appear to contribute to the risk of a peri-prosthetic fracture

INTRODUCTION. The purpose of this study was to determine the rate of complications and re-operations after operative treatment of peri-prosthetic femur fractures sustained within 90 days following primary total hip arthroplasty (THA). METHODS. 4,433 patients (5,196 consecutive primary THAs) over 10 years at a single institution were retrospectively reviewed. Thirty-five (0.67%) peri-prosthetic fractures that were treated operatively in 32 patients were identified and classified using the Vancouver Classification. There were 9 patients with a type Ag fracture, 2 patients with a type B1 fracture, 17 patients with a type B2 fracture, 1 patient with a type B3 fracture, and 3 patients with a concomitant type Ag and B2 fracture. Eleven (34%) patients were treated with isolated ORIF: greater trochanter (9) or femoral shaft (2). Twenty-one (66%) were treated with femoral revision combined with (14) or without (7) attempted fracture fragment reduction; a diaphseal engaging stem was utilized in all revisions. One patient was lost to follow-up leaving 31 patients for evaluation. RESULTS. Nineteen (61%) patients sustained twenty-two major complications including non-union of the greater trochanter in 10 of the 12 Ag fractures, three Brooker grade 3 heterotopic ossification (10%), non-unions of both B-1 fractures (6%), two deep infections (6%), one stem subsidence that required repeat revision (3%), one greater trochanteric fracture with instability (3%), one non-union of an extended trochanteric osteotomy, one hematoma (3%) and one peroneal nerve palsy (3%). Seven patients (23%) required a second operative procedure for management of a complication and one patient required a third operation. CONCLUSIONS. Operative treatment of acute post-operative periprosthetic fractures is associated with a high rate of major complications (61%) and re-operation (23%). Operative treatment of acute post-operative fractures of the greater trochanter was associated with non-union in 10 of 12 cases (83%)

INTRODUCTION. The number of patients undergoing total hip replacement surgery is rising and thus the number of periprosthetic fractures is set to increase. The risk factors for periprosthetic fractures include osteolysis, rheumatoid arthritis, osteoporosis and use of certain types of implants. Evidence from literature suggests that the mortality rate within one year is similar to that following treatment for hip fractures thus as surgeons it is important for us to understand the various management strategies of these fractures. MANAGEMENT. Acetabular periprosthetic fractures are uncommon and classified into Type I, in which the acetabular component is radiographically stable and Type II, in which the acetabular component is unstable. It is better to prevent than to treat these fractures. Femoral periprosthetic fractures have several classifications the most commonly used is the Vancouver classification (fig 1). Type-A fractures are proximal and can involve the greater or lesser trochanter. These are often related to osteolytic wear debris and therefore revision of the bearing surface with bone grafting is recommended. AG involves the greater trochanter and A. L. involves the lesser, and these can usually be stabilised by cerclage wires supplemented by screws or plates if required (fig 2). Management of type B fractures is more controversial and will be discussed in depth with reference to all recent papers at the meeting and data from the Swedish Joint Registry. In summary the management is shown in fig 3. In type-C fractures, one should ensure the fixation device bypasses the femoral stem by at least 2 diaphyseal diameters. Management is as shown in fig 4. DISCUSSION. The incidence of periprosthetic fractures is rising and effective management involves a multi-disciplinary approach, and begins with taking a careful history to identify co-morbidities, pre-fracture mobility, and pre-fracture symptoms of loosening or acetabular erosion. Use of NSAIDs and smoking status should be noted. Examination findings should focus on mental status, any signs of infection, neurovascular status and the integrity of the soft tissue envelope. Clear radiographs are required to effectively comment on bone quality and the identification of any pathological lesions. White cell count, CRP and ESR should help confirm the absence of infection and if any doubt exists, a pre-operative aspiration should be considered. Ideally surgery should be performed within 2 days of fracture by a revision arthroplasty surgeon, followed by monitoring on a high dependency unit. With regard to the formulation of an operative strategy, certainly there is no substitute for careful assessment of remaining bone stock, diameter of the canal, fracture configuration and patient-related factors. There is a paucity of data in the current literature relating to the management of acetabular fractures. Displaced femoral fractures are managed with cerclage fixation along with bone grafting of any osteolytic lesions and revision of the bearing surfaces. Regarding femoral periprosthetic fractures it would appear that one should err on the side of long stem revision arthroplasty +/− impaction allografting should any doubt exist around loosening of the implant since this reduces the one-year mortality rate and the risk of failure